Cirugía española
Prevención de la enfermedad tromboembólica venosa en cirugía generalPrevention of venous thromboembolic disease in general surgery

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Resumen

La enfermedad tromboembólica venosa (ETV) postoperatoria constituye una complicación que afecta aproximadamente a 1 de cada 4 pacientes quirúrgicos generales intervenidos y que no reciben medidas para su prevención. Además del riesgo de embolismo pulmonar, fatal en muchos casos, los pacientes que sufren ETV están expuestos a desarrollar complicaciones a largo plazo, tales como síndrome postrombótico o hipertensión pulmonar crónica. Por otra parte, la ETV postoperatoria suele ser asintomática o producir manifestaciones clínicas que se atribuyen a otros procesos, por lo que muchas veces esta complicación pasa desapercibida para el cirujano que intervino al paciente. Así pues, la mejor estrategia consiste en una eficaz prevención de la ETV, utilizando para ello las medidas profilácticas adecuadas al nivel de riesgo tromboembólico del paciente. Existe suficiente evidencia de que la ETV se puede prevenir mediante métodos farmacológicos, entre los que destacan la heparina y sus derivados, y con métodos mecánicos como las medias elásticas o los sistemas de compresión neumática intermitente de los miembros inferiores.

Con objeto de reducir en lo posible la incidencia de ETV postoperatoria, se han propuesto estrategias que incluyen la combinación de fármacos y métodos mecánicos, nuevos fármacos antitrombóticos, o prolongar la duración de la profilaxis en los casos de muy alto riesgo, como los operados por cáncer. Otro aspecto importante es el del momento óptimo de inicio de la profilaxis con los fármacos anticoagulantes, con objeto de conseguir un equilibrio adecuado entre la eficacia antitrombótica y el riesgo de presentación de complicaciones hemorrágicas. En este artículo revisamos la evidencia disponible para intentar optimizar en lo posible la prevención de la ETV en cirugía general y en algunos grupos especiales, como la cirugía laparoscópica, de corta estancia y de la obesidad.

Abstract

Postoperative venous thromboembolic disease (VTED) affects approximately one in four general surgery patients who do not receive preventive measures. In addition to the risk of pulmonary embolism, which is often fatal, patients with VTED may develop long-term complications such as post-thrombotic syndrome or chronic pulmonary hypertension. In addition, postoperative VTED is usually asymptomatic or produces clinical manifestations that are attributed to other processes and consequently this complication is often unnoticed by the surgeon who performed the procedure. Thus, the most effective strategy consists of effective prevention of VTED using the most appropriate prophylactic measures against the patient's thromboembolic risk. There is sufficient evidence that VTED can be prevented by pharmacological methods, especially heparin and its derivatives and with mechanical methods such as support tights or intermittent pneumatic compression of the lower extremities.

To reduce the incidence of VTED as far as possible, strategies have been proposed that include a combination of drugs and mechanical methods, new antithrombotic drugs, or prolonging the duration of prophylaxis in patients at very high risk, such as those who have undergone surgery for cancer. Another important aspect is the optimal moment to initiate prophylaxis with anticoagulant drugs with the aim of achieving an adequate equilibrium between antithrombotic efficacy and the risk of hemorrhagic complications. The present article reviews the available evidence to attempt to optimize prevention of VTED in general surgery and in some special groups, such as laparoscopic surgery, short-stay surgery and obesity.

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